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In the last decade, laparoscopic surgery had become popular in gynaecological surgery. Advantages of the minimally invasive approach are reduced postoperative morbidity, less postoperative pain and, consequently, less analgesic requirement, early resumption of intestinal activity and reduced length of hospital stay. Ectopic pregnancy occurs in approximately 1–2% of pregnancies and the incidence is increasing. The most common site of ectopic pregnancy is the ampullary tubal portion and less frequently other parts of the tube and uterus (cornual and caesarean scar pregnancy), the cervix, the ovary and the abdominal cavity are affected. All variants of extrauterine pregnancy can be treated by a minimally invasive approach in the majority of cases. Moreover, minimally invasive surgery can be considered the standard therapeutic option for adnexal masses which represent one of the most common gynaecological diseases. In this chapter, we describe the main surgical techniques concerning these two pathologies, which are of great interest for daily gynaecological practice.
A 28-year-old nulligravid woman presents reporting severe dysmenorrhea, deep dyspareunia, and dyschezia that worsens with menses. She states she has always had painful periods, but they have worsened over the past year. She describes it as sharp, twisting, and feels that something is “stabbing her from the inside out.” She is in a long-term relationship and desires future fertility. She has tried several different combined oral contraceptive pills, which mildly improved her pain. She has also tried non-steroidal anti-inflammatory drugs, medroxyprogesterone acetate, and a gonadotropin-releasing hormone agonist without relief. She states the dyspareunia and constipation have worsened over time. She underwent a diagnostic laparoscopy at age 26 and was told she had stage IV endometriosis. She continues to have debilitating pain that significantly impacts her quality of life. She would like to proceed with fertility-sparing surgical management. She has no other relevant relevant past medical or surgical history. She is currently taking oral contraceptives (ethinyl estradiol/norethindrone) and has no known drug allergies.
A 24-year-old female, gravida 0, presents to the office for follow-up of suspected endometriosis. Her last menstrual period started two days ago. She reports a three-year history of chronic pelvic pain that is worse during menses, is moderate to severe in intensity, and crampy in nature. She has tried combined oral contraceptive pills without symptomatic improvement. She denies fever, changes in bowel or bladder habits, or dyspareunia. She is sexually active with one male partner. She uses condoms regularly. She has no history of sexually transmitted infections. She has no significant past medical or surgical history.
A 16-year-old nulligravid female presents to the emergency department with abdominal pain. She reports the pain started suddenly two hours prior to arrival and is associated with nausea and vomiting. The pain comes and goes, is located in the right lower quadrant, and is described as sharp and stabbing. She rates the pain as nine out of ten. She denies fever, chills, urinary symptoms, diarrhea, and constipation. She reports never having been sexually active. She has no past medical or surgical history. She is not taking any medications and she has no known drug allergies.
A 34-year-old gravida 3, para 3 is undergoing an interval bilateral salpingectomy for permanent sterilization. She is currently using combined oral contraceptive pills (containing ethinyl estradiol/norethindrone) for contraception. Because of side effects associated with the pill, she has opted for permanent sterilization. She understands sterilization is a permanent procedure and is certain she has completed her family. Her pre-procedure pregnancy test was negative. All her deliveries were spontaneous vaginal deliveries. She has no history of easy bleeding or bruising. She has no past medical or surgical history. She is not taking any other medications and she has no known drug allergies.
A 40-year-old woman, gravida 3, para 3, with last menstrual period two weeks ago presents for evaluation of a palpable pelvic mass. She reports noticing a slow increase in her abdominal distention over the last four months; however, she denies abdominal pain. She denies any bowel or bladder dysfunction. She is sexually active and denies dyspareunia. Her sexual partner has had a vasectomy. She denies a personal history of breast cancer and denies any family history of breast, ovarian, or colon cancer. Her medical history is significant for anxiety. She has no past surgical history. She is currently taking citalopram. She has no know drug allergies.
Laparoscopic extensive myomectomy, hysterectomy for large myomas, laparoscopic treatment of endometriosis or treatment of cancer of the uterus are advanced laparoscopic gynaecological procedures. Since they can be very challenging, many special pre-, intra- and postoperative aspects need to be considered. This chapter aims to give insights into the different advanced laparoscopic gynaecological procedures. The preoperative arrangement, the intraoperative setting, key operative steps and the postoperative course are described in detail. An overview of common intraoperative complications like ureter injuries, bladder injuries, gastrointestinal injuries, vascular injuries and pneumoperitoneum-linked complications is given. Some typical postoperative complications like wound-healing problems, bleeding and gastrointestinal lesions are described together with possible treatment options.
Endometriosis is a chronic oestrogen-dependent condition that affects 10% of women from puberty to menopause. It is characterised by the presence and proliferation of endometrial-like cells outside the uterine cavity, generally within the pelvis. Endometriosis can present as superficial or deep peritoneal lesions, ovarian endometrioma or deep rectovaginal disease. The two hallmark symptoms of endometriosis are pelvic pain and infertility resulting in poor quality of life. There is no correlation between the extent of the disease and severity of symptoms. The true prevalence of the condition is not known, as it requires a laparoscopy to confirm the diagnosis. It is found in up to 30% of women with infertility and in 45% of those with pelvic pain. While there are several theories of pathogenesis, an interplay of genetic, hormonal, environmental and immunological factors is implicated in the development of endometriosis in susceptible women. Symptoms are managed with a combination of hormonal treatment and laparoscopic ablation or excision of lesions for pain and usually assisted reproduction for infertility. Endometriosis is prone to recurrence after treatment, requiring multiple contacts with healthcare and repeat surgery. Management of endometriosis requires an individualised approach based on the woman’s age, predominant symptoms and priorities, which are subject to change over time.
Endometriosis causes pain and infertility for millions of women worldwide. The prevalence of endometriosis is 6-10% in women of reproductive age, and 30-50% of women with pelvic pain and/or infertility. For definitive diagnosis and staging of endometriosis, a surgical procedure, generally a laparoscopy, is necessary to visualise disease implants. More recently, magnetic resonance imaging (MRI) has been used as a non-invasive tool in the diagnosis of deep endometriosis. The aim of treatment of endometriosis is to remove or reduce disease deposits. This may be attempted through medical or surgical means. Although assisted conception treatments such as ovulation induction with intrauterine insemination (IUI), or in vitro fertilisation (IVF), do not treat endometriosis per se, they can successfully treat the associated infertility. All couples presenting with failure to conceive should undergo a full evidence based fertility work-up. This includes a semen analysis, confirmation of ovulation and tubal patency testing.
Ovulatory disorders can arise from any level of the hypothalamic-pituitary-ovarian axis. Ovulatory dysfunction may result from a lack of available oocytes or of follicles. Pelvic imaging, which is often undertaken at the time of examination by transvaginal ultrasound scan, can confirm normal pelvic organs and also provide an assessment of ovarian morphology, in particular polycystic appearance. Semen analysis for the male partner must be considered an absolute minimum. It is important to consider tubal patency if ovulation induction is planned and, in women with risk factors for tubal disease, prior assessment should be considered mandatory either by laparoscopy or contrast imaging. Liaison with endocrine colleagues is recommended when more complex endocrine disorders are involved. General fertility advice is important, including advice (for both partners) on weight management, smoking, alcohol and drugs, as is confirming an up-to-date smear result and female folic acid supplementation.
Patients with early cervical cancer (FIGO stage IB1 or less) are conventionally considered treated with a surgical approach while those with more advanced disease are treated by radiotherapy with concurrent chemotherapy. Dargent's operation is the realization of a laparoscopic pelvic lymph-node dissection associated with a radical cervical amputation through a vaginal approach. Dargent's operation or radical trachelectomy enables preservation of fertility among women with early cervical cancer. The benefits of Dargent's operation are linked to the laparoscopic approach, which reduces the risk of adhesions on pelvis organs and the vaginal route that allows the preservation of uterine body and its optimal vascularization. Following the excellent results achieved by the Dargent's operation, several teams have proposed operating variants through laparotomy or laparoscopy. These modifications are subject to criticism because they are usually associated with the section of the uterine arteries and, thus, with a partial devascularization of the uterus.
Emergencies in gynaecological oncology are influenced by the site of cancer, stage of disease, presence of associated comorbidities and the treatment received. Women with advanced cervical cancer may develop distressing symptoms and may present with acute admissions. Vaginal bleeding caused by endometrial cancer can be usually managed conservatively. If there is an associated pyometra, operative treatment for endometrial cancer should be preceded by intravenous antibiotic treatment to avoid septicaemia and other septic postoperative complications. In severe cases, respiratory compromise may require omission of laparoscopy or conversion to laparotomy and postoperative ventilatory support. Catastrophic haemorrhage after gynaecological cancer surgery is uncommon, owing to the extensive use of electronic haemostatic devices; however, persistent oozing from large dissected surfaces may lead to haematomas. The most common complications, which require admission during chemotherapy, are febrile neutropenia and vomiting. Complications of radiotherapy depend on radiation-related factors and patient-related characteristics.
Usually investigation for infertility is carried out by gynecologists, because if a couple failed to conceive it has been traditionally expected that the woman has a problem and should visit a doctor. The general examination starts when the patient comes into the consulting room from observations of body habitus, skin, hair excess, gait and posture. Ultrasonography is a more accurate method compared with bimanual examination so more precise data about ovaries and uterus may be obtained with a transvaginal ultrasound probe than with palpation. The assessment of ovulation involves history, examination and investigation. At hysterosalpingography (HSG) radio-opaque dye is injected through the small canula via the cervix into the uterine cavity under X-ray screening. In patients with infertility, diagnostic hysteroscopy is usually combined with laparoscopy. X-chromosome abnormalities may affect fertility in women with Turner syndrome, especially in mosaic form.
Recurrent miscarriage (RM) affects between 1-2% of fertile couples and is a clinical condition of heterogeneous etiology. Parental structural chromosome rearrangements are reported in 3-8% of couples suffering recurrent miscarriage and testing of both partners is therefore recommended. Conventional cytogenetic analysis of miscarriage tissue from women with a history of RM has detected a 26-57% abnormality rate. In the RM population, the prevalence of reported uterine malformations range widely from between 1.8% to 37.6%. Diagnostic tools for detecting uterine anomalies include two- and three-dimensional ultrasound, hysteroscopy, laparoscopy and magnetic resonance imaging (MRI). The antiphospholipid syndrome (APS) remains entrenched as one of the most studied factors associated with RM. Natural killer (NK) cells are found in peripheral blood and within the endometrium and have been associated with RM. Presently, many of the RM investigations are controversial because of limited studies, inconsistent terminology and small and poorly designed treatment studies.
This chapter discusses the usefulness of ultrasound in diagnosing normal and abnormal fallopian tubes using two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography (TVS) and hysterosalpingo-contrast sonography (HyCoSy). HyCoSy involves the introduction of fluid into the uterine cavity and the fallopian tubes. The role of HyCoSy as a first-line procedure for the assessment of tubal patency has been examined in several studies. In most of the studies, the diagnostic capabilities of HyCoSy have been compared with the established reference methods of hysterosalpingography (HSG) or laparoscopy with dye insufflation, or both, and in the majority of the studies Echovist was used as the ultrasonographic contrast medium. A multicenter study in Scandinavia compared laparoscopic salpingectomy with no intervention prior to the first in vitro fertilization (IVF) cycle. The study demonstrated significant improvement in pregnancy and birth rates after salpingectomy in patients with hydrosalpinges that were large enough to be visible on ultrasound.
The classification of uterine anomalies divides the uterine septum into complete (septate) or partial (subseptate) groups according, respectively, to whether the septum approaches the internal os or does not. The complete septum that divides both the uterine cavity and the endocervical canal may be associated with a longitudinal vaginal septum. Although surgery (hysteroscopy, alone or with laparoscopy), constitutes the gold standard for the diagnosis of uterine septum, various imaging tools including hysterosalpingography (HSG), ultrasonography, and magnetic resonance imaging (MRI) have great value in the diagnosis, with high levels of accuracy. In infertility patients it is believed that incidentally discovered uterine septum and even arcuate uterus should be corrected hysteroscopically prior to any infertility treatment to enhance reproductive outcome. While the hysteroscopic approach for surgical resection of uterine septum is safe and effective, the choice of surgical technique (using sharp scissors or electrocautery) is an operator preference.
This chapter reviews the basic principles of radiologic tests, and describes the basic female anatomy. It provides information for appropriate imaging modalities for each part of the female genital tract. Currently ultrasound plays a role in monitoring the uterus during ovarian stimulation and early pregnancy. Assessment of uterine leiomyoma is historically achieved with ultrasonography, although computed tomography (CT) and magnetic resonance imaging (MRI) also offer detection of uterine fibroids. In reproductive medicine, imaging of the tubes is typically limited to evaluation of patency and distortion of normal anatomy, as in hydrosalpinges and salpingitis isthmica nodosum. Pituitary imaging is mostly performed in reproductive medicine for the infertile patient with persistently elevated prolactin levels or with levels over 100 ng/ml. Imaging is rarely performed in reproductive medicine specifically to evaluate for peritoneal disease. Laparoscopy is considered the gold standard for diagnosis of peritoneal processes such as endometriosis.
Tubal ectopic pregnancy is an important cause of maternal morbidity and mortality worldwide. Clinical presentation of ectopic pregnancy varies from mild vaginal bleeding to sudden rupture and massive intra-abdominal haemorrhage. The diagnosis of the ectopic pregnancy was made at surgery and then confirmed on histological examination following salpingectomy. At laparoscopy, an unruptured ectopic pregnancy typically presents as a well-defined swelling in the fallopian tube. The diagnosis of intrauterine pregnancy becomes more difficult if the uterus is enlarged by fibroids. Fibroids often distort the shape of the endometrial cavity and prevent the operator from visualising in a single plane the continuity between the gestation sac and the cervical canal. Surgery remains the main therapeutic option for the treatment of tubal ectopic pregnancy. Medical management of ectopic pregnancy has grown in popularity following observational studies which reported success rates greater than 90% with single-dose systemic methotrexate.
Female fertility begins to decline many years before menopause, despite continued regular ovulatory cycles. Decreased fecundity with increasing female age has long been recognized in demographic and epidemiological studies. Traditionally, the evaluation of the infertile female consists of: (i) ovulation assessment (ovulatory factors), (ii) evaluation of the uterine morphology (ovulation assessment) and tubal patency (tubal factors), (iii) assessment of the presence of pelvic pathology (by laparoscopy) (peritoneal factors), and (iv) postcoital test (cervical factors). Hysterosalpingography (HSG), laparoscopy are widely used in assessing infertility. Chlamydia antibody testing is a screening method for assessing tubal infertility. HSG, sonohysterography, hystero-salpingo contrast sonography (HyCoSy), magnetic resonance imaging (MRI) and hysteroscopy are used in assessment of uterine factors related to infertility. Currently, the best method to monitor ovulation is transvaginal ultrasound, which can be used to demonstrate the growth of a dominant follicle and provide presumptive evidence of ovulation and leutinization.
This chapter presents a comprehensive review of the reproductive problems that could be associated with uterine septum. The classification of uterine anomalies divides the uterine septum into complete (septate) or partial (subseptate) groups, according to whether the septum approaches the internal os or not, respectively. Although surgery (hysteroscopy, alone or with laparoscopy) constitutes the gold standard for the diagnosis of uterine septum, various imaging tools including hysterosalpingography (HSG), ultrasonography, and magnetic resonance imaging (MRI) have great value in the diagnosis with high level of accuracy. The hysteroscopic approach for surgical resection of uterine septum is a safe and effective approach. While generally it is an operator preference whether to utilize ablative energy, for example, electrical diathermy or laser, or to utilize sharp scissors without energy, the outcome of treatment is comparable as regards complication and reproductive performance after surgery.